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HomeMy WebLinkAboutBLDX-26-616 application RECEIVED Office Use Only 1;4e. °� JUN 15 2026 PermiW o ,NfHy Amount rot) BUILDING �`�e Eo,.� ay. DEPARTMENT EXPRESS BUILDING PERMIT APPLICATION TOWN OF YARMOUTH Yarmouth Building Department 1146 Route 28 South Yarmouth,MA 02664 (508)(�398-2231 Ext.,1261 � Z 6 y CONSTRUCTION ADDRESS: !"I1 0 / oPf V' MIS �` ySf-„fr, d e OWNER: 6 I .54.G(i+64 /'t 6 1/41r7 . Oei r P y; MJ✓tom PV' tJ266y NAME (� �•7P�RESENT ADDRESS TEL.# CONTRACTOR:�1 iI 11 i°417 I S laver L P y 1( )9e 1 W cep 6 NAME ///�� MAILING ADDRESS TEL#sock, 7tdd 2 76e EMAIL: I t to Ire h 5 66Cs) YMG: •t!drry Of Residential 0 Commercial L Est.Cost of Construction S / (�5 Uv Homeowner is Applicant?Yes No 7 Home Improvement Contractor Lie.# (L()053 Construction Supervisor Lie.# 9y3s1 WORK TO BE PERFORMED Tent Duration (Fire Retardant Certificate required) Wood Stove Siding: #of Squares Replacement windows:# Replacement doors: # Rooting: #of Squares /6 Insulation Temporary Mobile Home Temporary Construction Trailer Demolition—Interior only Demolition Raze Structure Solar System_ ESS System Chimney_ Fence *Please submit utility disconnect letters for electric&gas—structures over 75 years old require historical review .The debris will be disposed of at: V4fti O)Iz, / A Location of Facility I declare under penalties of perjury that the statements herein contained are true and correct to the best of my knowledge and belief.I understand that any false answer(s) will be just muse for denial or revocation of my license and for prosecution under M.G.L.Ch.268,Section I. /` / Applicant's Signature: Date: 6//Si 2 4 Owners Signature(or attachment) Date: Approved By: Date: Building Official for designee) Rev 6/24 The Commonwealth of Massachusetts Department of Industrial Accidents Ti----'', ' Office of Investigations _' Lafayette City Center 2 Avenue de Lafayette, Boston,MA 02111-1750 ' _ .:._., y` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lei ibly Name (Business/Organization/Individual): k 0 .1—t/1 Address: .Sf I-Owcc ,gr i— ?c City/State/Zip: Y4 rrn pv i1 10 (j Z � Phone#: .Uct /6° 2)U Are you an employer? Check the appropriate box: Type of project(required): 1. I am a employer with ( 4. ❑ [am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. gRemodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9 ID Building addition [No workers' comp. insurance comp. insurance.- required.] 5. ❑ We are a corporation and its 10.1=1 Electrical repairs or additions 3.❑ [am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.1:1 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: (NA Policy#or Self-ins. Lic. #: 6-s5'' U B Cf Z 2. v.3 7 Z2( Expiration Date: 3)s/ 27 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: 6/ (S / ei Phone#: ScS- 760 Z -7°Z Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(check one): 10Board of Health 20 Building Department 3EICity/Town Clerk 4.0 Electrical Inspector 50Plumbing Inspector 6.0Other Contact Person: Phone#: Keating Construction Home improvement contractor registration DATE 20, 2026 143053 Quotation # 54 Lower Brook Rd So Yarmouth MA 02664 Phone (508) 760 2702 timkeat,n hotmc rim Proposal for: Job name! location: Brian Stanton Same 140 North Dennis Rd Yarmouth Ma 02664 We hearby submit specificatons and '' _ -�7^"� ,: 4� : , �.., F CMS• x 'i-+.-c`f+, k -Y -o .: `'`u` � 4-., r .. .. n Strip roof shingles off entire house install 5/8 plywood over existing decking install Certainteed water and ice shield on lower edges,valeys and chimney Install new vent pipe flanges and 30 lb tar paper on decking Install new white 8 inch drip edge on eves and rakes Install Certainteed Landmark 30 yr architectural shingles Ail debris and trash will be removed and disposed of properly ti ss z �s.w .1 wi s t y.^b32 gr Cx{�T ._F,�24t,s�,�'.'��5_,t ; Q."�T rr,.�.,a ?�^ � =`V.a��s"�., ��. 1+r. �£...t}. s ?�'!�M1.f, k...''` r, _. t SK� :anrl"s Only items specified above are included in this proposal Chimney flashing replacement is not included in this proposal Rotted wood repair is riot included in this proposal $35 00 per hr + materials if needed Materials guaranteed by manufacturers Workmanship guaranteed by Keating Construction for 10 years. We propose hereby to furnish materials and labor for the sum of: $14 500 00 0244+,,i'V�, 1/3 payment due at start of job and remainder upon completion Acceptance of Proposal: Date of accetance: Ki d 1 Acceptance of Proposal: Date of acceptance: Tile above prices, specifications and conditions are satisfactory and are hereby accepted 4 4 • OMNI § •'' A dr. t3^ y r_i,� ' __ n 6/15/26,6:02AM Deals Licensee Details Demographic Information ull Name: Tmothy B Keating ner Name: License Address Information _ ity: South Yarmouth tate: MA pcode: 02664 oust : United States License Information License No: CSSL-099351 License Type: CSSL-RF-Roofing Profession: Building Licenses Date of Last Renewal: 5/1/2026 Issue Date: 6/4/2008 Expiration Date: 5/11/2028 License Status: Active Today's Date: 6/15/20265/14/2026 Secondary License Type: Doing Business As: i,Status Change Reason: License Renewal Prerequisite Information Licensee: Keating,Timothy B Relationship: Attribute Of License No: CSSL-099351 No Available Documents file:p/C:/Users/Tim/Desktop/26 w/CSL 26.html 1/1 irOituinitAri I Or: 1,11/ 9If • . ' •*, oi.h.rrrialv 9enT.11 ..,S0 lc'I • .rrto 7tii I^di ityptiwei Home Improvement Contractor Registration Card Registration valid for use type, only before the expiration date. ,.ti►1�� Type: Individual +‘ Number: 143053 Expiration: 06/14/2028 Issued to: * • Keating Construction TIMOTHY KEATING tim B keating 54 LOWER BROOK RD. SO. YARMOUTH, MA 02664 21 K. Y&41dL J Office of Consumer Affairs & Business Regulation La,✓y/a R. D'Emrlia 1 Federal St., Suite 0720, Boston, MA 02110-2012 Undersecretary ,4c caT>F(t�erDrYrrY)R,D CERTIFICATE OF LIABILITY INSURANCE 04r06/26 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER ACT NAME:: PAUL SCHLEGEL WORLD INSURANCE ASSOCIATES LLC PHONE o.Estl: 508-771-8381 INC,FAX No). 508-771-0663 34 Main Street E-MAIL West Yarmouth,MA 02673 ADDRESS: schlegelinsurance@gmail.com INSURER(S)AFFORDING COVERAGE NAIC U INSURER A: TRISURASPECIALTY INSURED INSURER B: CONTINENTAL CASUALTY TIMOTHY KEATING DBA KEATING INSURER C: CONSTRUCTION 54 LOWER BROOK RD INSURER D SOUTH YARMOUTH, MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INKS 2— {ADDL aUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE IINSD WVD POLICY NUMBER (MMJDD/YYYY) (MMIDDIYYYY) LIMITS X COMMERCIAL GENERAL I IARII ITY EACH OCCURRENCE $ 1,000,000 D CLAIMS-MADE [X]OCCUR DAMAGE ST(Ea occurrence) 500,000 PREMISES(Ca occurrence) $ MED EXP(Any one person) $ 10,000 A NRG-DBG-1647180-001 03/19/26 03/19/27 PERSONAL 8 ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea acc,dent) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTIVE N NIA 6S59UB0224N37226 03/09/26 03/09/27 E.L.EACH ACCIDENT $ 100,000 B OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,descnbe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) TIMOTHY KEATING HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY INSURANCE COVERAGE IS LIMITED TO THE TERMS,CONDITIONS, EXCLUSIONS AND OTHER LIMITATIONS AND ENDORSEMENTS OF THE POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN TOWN OF YARMOUTH ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT - YARMOUTH MA AUTHIZED REP NTA • ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD